Laserfiche WebLink
SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> FOH OFFICE USE: 1601 E, Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP -PERMIT Permit No. ? Z�Sr/ <br /> THIS .PERMIT. EXPIRES I: YEAR FROM DATE ISSUED <br /> � Date Issued //�/'�• 7� <br /> � Application is hereby made In Triplicate) <br /> to the San Je <br /> Joaquin Health Districtf r <br /> 'a permitand/or install the work herein described. ,This application is made incompliancetwithnst Sanuct Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local. Health District.{ <br /> k � <br /> JOB ADDRESS/LOCATION ' <br /> J�1 CENSUS TRACT <br /> Owner's Name <br /> t Phone <br /> Address N <br /> Cit <br /> Contractor's Name ` . <br /> kLicense -------------- Phone �i1� <br /> TYPE OF WORK (Check) : NEW WELL <br /> DEEPEN/7/- RECONDITION / DESTRUCTION /7 <br /> PUMP INSTALLATION / / PUMP REPAIR / PUMP REPLACEMENT <br /> G Other <br /> DISTANCE TO NEAREST: SEPTIC TANKS" <br /> SEWER LTNES PIT PRIVY _--- <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT <br /> PROPERTY LINE _ PRIVATE DOMESTIC WELL PUBLIC DOMESTICOTHER WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial <br /> Gable Tool Dia, of Well Excavation <br /> Domestic/private Drilled ' .-Dia. of Well Casing <br /> Domestic/public Driven <br /> Irrigation '�Gabge of Casing <br /> 1 Gravel Pack ` .Depth of Grout Seal <br /> Cathodic Protection 3 Rotary Type of Grout <br /> Disposal i Other Other Information <br /> Geophysical <br /> Surface Seal Installed B : <br /> PUMP INSTALLATION: <br /> Contractor <br /> Type of Pumpr <br /> H.P, <br /> PUMP REPLACEMENT: ! �� -�-; - <br /> / / State Work`Dono' <br /> PUMP REPAIR: State Woxk'Done . <br /> DESTRUCTION OF WELL: Well Diameter <br /> Describe 'Material and Procedure ` Approximate Depth <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health Dist i t <br /> and the State of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> t <br /> after completion of my work on1-a-new-well, 1 'will furnish the San Joaquin Local Health Distract ,a <br /> WELL DRILLERS+REPORT-of the well and notify them before putting_ the. well in use.. The above <br /> information is tzne to the,. b an <br /> t of my knowledge d belief. <br />°RIOR TO GROU AND A FI I WILi'' CALL FOR A GROUT INSPECTION <br /> SIGNED S ECTIUN <br /> TITLE , <br /> (DRAW PLOT PLAN ON REVERSE SIDE <br /> DEPARTMENT USE ONLY <br /> PHASE I FOR <br /> APPLICATION ACCEPTED BY <br /> ADDITIONAL COMMENTS: DATE <br /> INSPECTION BY <br /> PHASE II GROUT INSPECTION PHASE III/FINAL INSPECTTON <br /> BATE INSPECTION BY <br /> DATE 3 �,3D•7„� <br /> E H 1426 Rev. • 1-74 0177 part <br />